Smoking Cessation Assisting the patient who wants to quit

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Smoking Cessation(Assisting the patient who
wants to quit)
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Scope of the Problem (USA)

• 21 of US citizens use tobacco products (mostly
  cigarettes)
• 440,000 deaths each year attributable to tobacco
  use 1 cause of death and disease
• Heart Disease 700,142
• Cancer 553,768
• Stroke 163,538
• Chronic Respiratory Disease 123,013
• 4,000 children and teens become regular users of
  tobacco each day
• Direct medical care costs estimated to be 50
  billion annually loss of productivity costs 47
  billion
• 70 of smokers have made at least 1 attempt to
  quit or want to quit 48 try to quit each year

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Cigarette Smokers by Race and Education

• American Indians/Alaskan natives 40.8
• Whites 23.6
• African Americans 22.4
• Hispanics 16.7
• Asians 13.3
• GED 42.3
• 9-11 years of education 34.1
• Undergrad college degree 12.1
• Graduate college degree 7.2

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Scope of the Problem in Kentucky

• 27.6 of the KY population are cigarette smokers
  (highest in nation!)
• W.Va. 27, TN 26, OK 26, OH 26
• Utah 10.5, CA 14.8, ID 17.5, CN 18, AZ 19
• Males 23.4, Females 18.5
• 34 of KY high school students (23 nationally)
• 15 of KY middle school students (10 nationally)
• Smokeless tobacco use 25 high school boys, 20
  middle school boys
• 25 of pregnant women smoke
• Not surprisingly, Kentucky has
• Highest smoking-related death rate in the nation
  (444/100,000)
• One of the highest lung cancer death rates in the
  nation(53/100,000)

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Economics of Cigarette Smoking(Kentucky has one
of the lowest excise tax rates/pack in nation at
30 New York is the highest at 3/pack)

• Assuming that the cost of 1 pack of cigarettes
  3
• Daily cost 1PPD 3 2PPD 6 3PPD 9
• Weekly cost 1PPD 21 2PPD 42 3PPD 63
• Monthly cost 1PPD 84 2PPD 168 3PPD
  252
• Yearly cost 1PPD 1,008 2PPD 2,016
• 3PPD 3,024

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Diseases Associated With Tobacco Use

• Cardiovascular Disease 2-4x risk (coronary heart
  disease, myocardial infarction, peripheral
  vascular disease 10x risk, stroke 2x risk)
• Pulmonary Disease 10x risk (emphysema, chronic
  bronchitis, asthma, lung cancer 12-22x risk)
• Pregnancy (stillbirth, spontaneous abortion, ?
  fetal growth, premature birth, LBW, SIDS, oral
  clefts)
• Cigarette smokers die 13-14 years earlier than
  non-smokers

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Oral Disease Associated with Tobacco Use

• Gingival inflammation and recession
• Periodontal disease
• Implant failure
• Smokers melanosis
• Nicotine stomatitis
• Leukoplakia
• Tobacco pouch keratosis
• Erythroplakia
• Verrucous carcinoma
• Squamous cell carcinoma

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Other Oral Effects Associatedwith Tobacco Use

• Staining
• Abrasion
• Halitosis
• Hairy tongue
• Diminished
• taste and smell

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Benefits of Quitting(From US Surgeon General)

• 20 Minutes After QuittingYour heart rate drops.
• 12 hours After QuittingCarbon monoxide level in
  your blood drops to normal.
• 2 Weeks to 3 Months After QuittingYour heart
  attack risk begins to drop.Your lung function
  begins to improve.
• 1 to 9 Months After QuittingYour Coughing and
  shortness of breath decrease.
• 1 Year After QuittingYour added risk of coronary
  heart disease is half that of a smokers.
• 5 Years After QuittingYour stroke risk is
  reduced to that of a nonsmokers 5-15 years after
  quitting.
• 10 Years After QuittingYour lung cancer death
  rate is about half that of a smokers.Your risk
  of cancers of the mouth, throat, esophagus,
  bladder, kidney, and pancreas decreases.
• 15 Years After QuittingYour risk of coronary
  heart disease is back to that of a nonsmokers.

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Visible and Immediate Rewards

• Quitting helps stop the damaging effects of
  tobacco on appearance including
• premature wrinkling of the skin
• bad breath
• stained teeth
• gum disease
• bad smelling clothes and hair
• yellow fingernails
• Kicking the tobacco habit also offers benefits
  that will be noticed immediately and some that
  will develop gradually in the first few weeks.
  These rewards can improve day-to-day life
  substantially
• Food tastes better.
• Sense of smell returns to normal.
• Ordinary activities no longer leave you out of
  breath (climbing stairs, light housework, et
  cetera.)

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Why is it so hard to quit?

• Cigarettes and other forms of tobacco are
  extremely addicting.
• Nicotine is the drug that causes addiction.
• Pharmacologic and behavioral characteristics that
  determine nicotine addiction are similar to those
  that determine addiction to drugs such as heroin
  and cocaine.
• Some evidence suggests that nicotine may be the
  most addicting drug of all

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Withdrawal Symptoms for Nicotine

• Dysphoric or depressed mood
• Insomnia
• Irritability, frustration, anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Decreased heart rate
• Increased appetite

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How Can We as Dentists Help?

• Clinical Practice Guidelines
• (Quick Reference Guide For Clinicians)
• U.S. Department of Health and Human Services
• Public Health Service, 2000
• Gold Standard the 5 As
• Ask
• Advise
• Assess
• Assist
• Arrange

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ASK

• Ask every patient about tobacco use
• Current user
• How long used
• Form of tobacco used
• Quantity used daily
• Ask if they have considered quitting or are
  interested in quitting
• Ask about previous attempts to quit and reasons
  for failure

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ADVISE

• Urge the tobacco user to quit, but dont badger
  or shame them
• Relate their tobacco use with their oral
  condition (periodontal disease, lesions,
  halitosis, taste complaints)
• Emphasize the benefits of quitting
• Tell your patient that you will help them if they
  want to quit

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ASSESS

• Asses readiness to quit
• be professional, gently persistent, and
  supportive
• Ask directly Do you want to quit?
• If willing, move on to the assist phase
• If unwilling, continue to provide motivational
  intervention at every opportunity
• Be alert for teaching moments

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ASSIST/ARRANGE(Several options)

• Provide self-help materials
• You Can Quit Smoking
• Benefits of Quitting
• Refer patient to a counseling source (telephone
  help line)
• Coordinate a smoking cessation program for the
  patient
• Provide NRPs or medications for the patient if
  desired
• Refer patient to a smoking cessation program
• Cooper Clayton program administered through
  county health departments in Kentucky

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How successful are we at getting patients to stop
smoking???
Not very good!!
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Quit Rates at 1Year

• Cold turkey quitting on their own (3-5)
• Brief interventions or help lines alone (doubles
  the chances of success)
• NRT alone (doubles the chances of success)
• Pharmacotherapeutic agents alone (double or
  triple chances of success)
• Combination of NRT brief interventions or help
  lines (doubles or triples the chances of success)
• Combination NRT PHT (doubles or triples chances
  of success)
• Cooper/Clayton program-NRT counseling (probably
  best of all)

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Level of Nicotine Dependence

• Level of nicotine dependence
• Direct relationship with outcome
• The higher the dependence, the more difficult it
  will be for the patient to quit
• The higher the dependence, the greater the
  likelihood that pharmacotherapy or multiple
  pharmacotherapy will be needed

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Quit Lines/Help Lines

• Kentucky 1-800-QUIT NOW
• 1-800-4-CANCER select option 3 (Cancer
  Information Service/ National Cancer Institute)
• 1-877-44-U-QUIT (Dedicated quit smoking help line
  of the National Cancer Institute)
• 1-866-66-START (Great Start Quitline for
  Pregnant Patients)
• 1-877-YES-QUIT (American Cancer Society Quitline)

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Nicotine Replacement Products

• Nicotine Replacement Therapy (NRT)
• Nicotine patch (Nicoderm OTC)
• Nicotine gum (Nicorette OTC)
• Nicotine lozenge (Commit OTC)
• Nicotine inhaler (Nicotrol Rx)
• Nicotine nasal spray (Nicotrol NS Rx)

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Rationale Behind NRT

• Smokers need to maintain a blood level of
  nicotine around 15-18 ng/ml in order to prevent
  withdrawal symptoms
• A single cigarette increases blood level of
  nicotine to 35-40 ng/ml (the rush)
• After about 25-30 minutes, the blood level falls
  back to 15-18 ng/ml
• NRT aims to provide a steady blood level of
  around 17 ng/ml in order to prevent withdrawal
  symptoms but without giving the reward of the
  rush
• Progressively learn to accept smaller and smaller
  blood nicotine levels and then ultimately zero

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NRT Nicotine Transdermal Patch(Available OTC)

• Nicoderm CQ Generic 3 strengths (21mg, 14mg,
  7mg)
• Nicotrol 1 strength (15mg)
• Dosages
• Nicoderm CQ or generic
• 1-21mg patch/day for 6 weeks, then
• 1-14mg patch/day for 2 weeks, then
• 1-7 mg patch/day for 2 weeks
• Nicotrol
• 1-15mg patch/day for no more than 16 hours
• per day for 8 weeks

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NRT Nicotine Polacrilex (Gum)(Available OTC)

• Nicorette Nicorette Mint 2 strengths (2mg and
  4mg)
• Chewed briefly, then parked for 30 minutes
  good control clock regulated better than prn
• Dosage
• use 4mg gum up to 24 pieces per day 2 weeks at
  12/day, then 1 week at 10/day, then 1 week at
  9/day, etc.

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NRT Nicotine Lozenge(Available OTC)

• Commit 2 strengths (2mg and 4mg)
• Parked between cheek and gum periodically
  moistened by placing on tongue and wetting with
  saliva
• Provides 25 higher blood levels than gum
• Absorption results in blood level of 86 of dose,
  but swallowing results in only 2 of dose
• Dosage
• Use 12 - 4gm lozenges per day, 1 about every 80
  minutes maximum 20 pieces/day

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Use of Gum or Lozenges

• Assume 1mg nicotine/cigarette x smoked/day
• Goal is 80 replacement as beginning point
• Both 4mg Nicorette and 4mg Commit deliver 2mg
  nicotine (if used correctly!)
• Example 1 pack/day 20 cigarettes 20mg
  nicotine/day 80 of 20 16mg nicotine
• 16mg 8 pieces of 4mg gum or 8 4mg lozenges/day
  on a fixed schedule

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Sample NRT Schedule

• Waking hours 16 hrs or 960 minutes
• 960 minutes/8 pieces 120 minutes (2 hr) between
  pieces
• Reduction schedule
• Week 1, 1 piece every 120 minutes
• Week 2, only 7 pieces used skipping the first
  piece(s) upon arising
• In each subsequent week, one less piece is used
  each morning of that week
• After 9 weeks, no further pieces

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NRT Nicotine Nasal Spray(Prescription only)

• Nicotrol NS
• Rapidly absorbed produces good nicotine blood
  levels good control
• Good choice for very dependent user
• Dosage
• 8-40 doses/day for 3-6 months
• A dose is 1 puff/nostril (6ng/ml)
• 3 doses/hour for 2 weeks, then
• 2 doses/hour for 4 weeks, then
• 1 dose/hour for 4 weeks

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NRT Nicotine Inhaler(Prescription only)

• Nicotrol inhaler (cartridges)
• Similar to smoking rapid absorption
• Generally not able to achieve optimum blood
  nicotine levels not the best choice for very
  dependent users very
• ineffective expensive
• Dosage
• 6-16 cartridges/day for up to 6 months

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Non-NRT Pharmacotherapeutic Agents

• FDA Approved for smoking cessation
• Bupropion (Wellbutrin)
• Varenicline (Chantix)
• Non-FDA approved
• Nortriptyline (Pamelor)
• tricyclic antidepressant
• Clonidine (Catapres)
• a-2 adrenergic agonist antihypertensive

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Bupropion SR(Prescription only)

• Zyban an antidepressant (Wellbutrin) but in a
  sustained release form
• As effective as nicotine patches when used alone
• 1 year quit rate about 10-15
• May be additional benefit when used in
  combination with other NRT
• Dosage
• 150mg tablets
• Start 1-2 weeks before quit date
• Take a 150mg tablet QD for 3 days, then BID
  thereafter continue for 7-12 weeks may need to
  continue for up to 6 months

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Varenicline(Prescription only)

• Chantix a unique medication that partially
  activates nicotine receptors to reduce the
  severity of craving for cigarettes and withdrawal
  symptoms
• Doubles the likelihood of quitting over bupropion
  and quadruples it over placebo
• 1 year quit rate with varenicline alone is 22
• Dosage
• 0.5 and 1.0 mg tablets
• Start 1 week prior to quit date
• 0.5 mg daily for 3 days, then 0.5 mg twice a day
  for 4 days, then 1.0 mg twice daily for 12 weeks

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Cooper/Clayton Method of Smoking Cessation

• A 12 week program providing weekly education
  sessions in a support group setting, which
  incorporates the use of NRT
• Available through many health departments in
  Kentucky
• Cooper/Clayton Office [phone]
• Fayette County Health Department [phone]
• Fee No cost for group sessions NRT medications
  will cost 300-400
• There is a self instructional DVD and book that
  is available for 29.95

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Ordering Cooper/ Clayton Materials

• Book 12
• Video or DVD (includes book) 75
• Contact
• Institute for Comprehensive Behavioral Smoking
  Cessation
• 1120 Buttonwood Ct.
• Lexington, KY 40515
• Phone [phone]

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